Inspection Report Summary
The most recent inspection on December 27, 2024, found no deficiencies, confirming that previously cited issues were corrected. Earlier inspections showed a pattern of deficiencies related primarily to infection control, medication management, abuse reporting, and preventive care for residents at risk of skin breakdown. Several complaint investigations were substantiated, particularly in late 2024, involving failure to timely report and investigate abuse, incomplete care planning, and infection control lapses. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates improvement over time, with recent surveys showing correction of prior deficiencies.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
16.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
231% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
21 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 9
Date: Jul 2, 2025
Visit Reason
The inspection was conducted to investigate multiple complaints regarding resident care, medication administration, abuse allegations, fall prevention, and catheter care at Sadie G. Mays Health & Rehabilitation Center.
Complaint Details
The investigation was complaint-driven, triggered by multiple allegations including failure to provide ordered care, medication errors, abuse allegations, and inadequate supervision. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity due to lack of urinary drainage bags, failure to notify providers and representatives of missed medications, failure to timely report and investigate abuse allegations, failure to update care plans after falls, inadequate assistance with activities of daily living, failure to administer medications as ordered, inadequate supervision to prevent accidents, and improper positioning of urinary drainage bags leading to potential urinary tract infections.
Deficiencies (9)
Failed to maintain the dignity of one resident by not providing urinary drainage bags as ordered, resulting in use of adult incontinence briefs.
Failed to notify providers and resident representatives when seven residents were not administered medications as ordered.
Failed to timely report allegations of abuse to required agencies and physician for two residents.
Failed to conduct thorough investigations of alleged abuse for two residents.
Failed to revise care plans related to falls for four residents, missing recent fall incidents.
Failed to provide adequate assistance with activities of daily living for one resident.
Failed to administer medications as ordered for seven residents, resulting in missed doses.
Failed to provide adequate supervision to prevent accidents for two residents, resulting in falls and injury.
Failed to properly position urinary drainage bags for two residents, risking urinary tract infections.
Report Facts
Residents affected: 21
Residents affected: 7
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 7 | LPN | Named in medication administration deficiency for signing medications as administered when they were not given |
| Certified Nursing Assistant 3 | CNA | Observed improper urinary drainage bag positioning and leakage |
| Director of Nursing | DON | Confirmed improper urinary drainage bag positioning and failure to update care plans |
| Administrator | Interviewed regarding abuse investigations and medication administration failures | |
| Infection Control Preventionist | Interim DON | Confirmed failure to timely report abuse and incomplete investigations |
| Unit Manager | UM | Responsible for shower schedule and documentation |
| Licensed Practical Nurse 1 | LPN | Discussed care plan updates and interventions such as Geri chair |
| Director of Rehab Services | DOR | Discussed use of Geri chair as intervention |
| Consultant Pharmacist | Aware of medication administration issues | |
| Nurse Practitioner 1 | NP | Interviewed about notification of medication errors |
| Nurse Practitioner 2 | NP | Interviewed about notification of medication errors and resident care |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 27, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Sadie G. Mays Health & Rehabilitation Center following a regulatory inspection.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 148
Deficiencies: 0
Date: Dec 27, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the Recertification-Complaint Survey concluded on 2024-10-24.
Findings
All deficiencies cited in the prior Recertification-Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 26, 2024
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies have been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Oct 24, 2024
Visit Reason
The inspection was conducted due to complaints alleging failure to timely report suspected abuse, failure to thoroughly investigate abuse allegations, incomplete Minimum Data Set (MDS) assessments, failure to develop baseline care plans, inadequate pressure ulcer care, infection control deficiencies, improper medication administration, lack of antibiotic stewardship, and non-functioning call light systems.
Complaint Details
The complaint investigation revealed failures in timely reporting and investigation of abuse allegations involving residents R10, R98, R108, R96, and R3. The facility also failed to complete quarterly MDS assessments for residents R33 and R405, did not develop baseline care plans for resident R355, and had deficiencies in pressure ulcer care for resident R455. Infection control lapses were noted for residents R20, R68, R607, and R74. Additionally, the antibiotic stewardship program lacked proper monitoring and documentation. Resident R23's call light system was found non-functional, compromising resident safety.
Findings
The facility failed to timely report and thoroughly investigate allegations of sexual abuse involving multiple residents. Quarterly MDS assessments were not completed for some residents. Baseline care plans were missing for residents with specific needs. Pressure ulcer care was inadequate due to inconsistent repositioning. Infection control practices were deficient, including improper handling and cleaning of nebulizers, oxygen equipment, bedpans, and medication carts. The antibiotic stewardship program lacked documentation and monitoring. One resident's call light system was non-functional, posing a risk to resident safety.
Deficiencies (8)
Failed to timely report suspected abuse and report investigation results to proper authorities.
Failed to respond appropriately to all alleged violations and complete thorough investigations of abuse.
Failed to ensure Minimum Data Set (MDS) assessments were completed quarterly for two residents.
Failed to create and implement a baseline care plan within 48 hours for a resident admitted with a catheter.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing due to inadequate repositioning.
Failed to ensure infection prevention and control program compliance including proper cleaning and storage of nebulizers, oxygen concentrators, bedpans, and medication carts.
Failed to implement a program that monitors antibiotic use and maintain documentation of antibiotic prescribing practices.
Failed to ensure a working call system was available in a resident's bathroom and bathing area.
Report Facts
Opportunities for repositioning: 96
Times repositioned: 59
BIMS score: 4
BIMS score: 9
BIMS score: 13
BIMS score: 5
BIMS score: 7
Number of residents sampled: 58
Number of residents affected by call light deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Documented incidents of alleged sexual abuse involving resident R98. |
| LPN CC | Licensed Practical Nurse | Documented incident of resident R98 grabbing resident R10's breast. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse reporting, investigation responsibilities, MDS assessments, infection control, and medication administration. |
| Administrator | Facility Administrator | Interviewed regarding abuse reporting, investigation, and facility policies. |
| Social Services Director | Social Services Director (SSD) | Notified of abuse incidents involving residents. |
| MDS Coordinator NN | Minimum Data Set Coordinator / Licensed Practical Nurse | Confirmed missing MDS assessments and baseline care plans. |
| MDS Coordinator OO | Minimum Data Set Coordinator | Confirmed missing MDS assessments. |
| CNA LL | Certified Nurse Assistant | Provided information on oxygen and nebulizer use and infection control. |
| LPN MM | Licensed Practical Nurse | Discussed expectations for oxygen concentrator and nebulizer maintenance. |
| Unit Manager D Hall | Unit Manager | Commented on improper storage of bedpans. |
| Maintenance Director | Maintenance Director | Discussed call light system checks and repairs. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Oct 24, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse, failure to respond appropriately to alleged violations, failure to complete quarterly Minimum Data Set (MDS) assessments, failure to create baseline care plans, failure to provide appropriate pressure ulcer care, failure to implement infection prevention and control, failure to maintain antibiotic stewardship, and failure to ensure a working call system in resident bathrooms.
Complaint Details
The complaint investigation revealed multiple failures related to abuse reporting and investigation, MDS assessments, care planning, pressure ulcer care, infection control, antibiotic stewardship, and call light functionality. Specific substantiation details include failure to report sexual abuse allegations timely for residents R10 and R108, incomplete investigations for residents R98, R96, and R3, and failure to maintain infection control and antibiotic stewardship documentation and practices.
Findings
The facility failed to timely report allegations of sexual abuse for multiple residents, failed to complete thorough investigations of abuse allegations, failed to complete quarterly MDS assessments for some residents, failed to develop baseline care plans for residents with catheters, failed to provide adequate pressure ulcer care including repositioning, failed to maintain infection control practices including proper cleaning and storage of nebulizers, oxygen equipment, bedpans, and medication carts, failed to maintain an effective antibiotic stewardship program with proper tracking and review, and failed to ensure a working call light system for a resident's bathroom.
Deficiencies (8)
Failure to timely report suspected abuse and failure to report results of investigations to proper authorities.
Failure to respond appropriately to all alleged violations including incomplete investigations of abuse.
Failure to ensure Minimum Data Set (MDS) assessments were completed quarterly for two residents.
Failure to create and implement a baseline care plan within 48 hours for a resident admitted with a catheter.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to reposition a resident as ordered.
Failure to provide and implement an infection prevention and control program, including failure to properly clean and store nebulizers, oxygen concentrator tubing, bedpans, and medication carts.
Failure to implement a program that monitors antibiotic use, including failure to maintain review and documentation of antibiotic prescribing practices for nine months.
Failure to ensure a working call system was available in a resident's bathroom and bathing area.
Report Facts
Opportunities for repositioning: 96
Repositionings documented: 59
BIMS score: 4
BIMS score: 9
BIMS score: 13
BIMS score: 5
BIMS score: 7
Residents sampled: 58
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Licensed Practical Nurse (LPN) | Documented incidents of abuse involving resident R98 and provided interview statements regarding reporting. |
| CC | Licensed Practical Nurse (LPN) | Documented nursing progress notes regarding abuse incidents involving residents R98 and R10. |
| Administrator | Administrator and Abuse Coordinator | Responsible for abuse reporting and investigation; confirmed delayed reporting and incomplete investigations. |
| Director of Nursing (DON) | Director of Nursing | Confirmed abuse reporting requirements, investigation responsibilities, and expectations for MDS assessments and infection control. |
| NN | Minimum Data Set Coordinator (MDSC) / Licensed Practical Nurse (LPN) | Confirmed failure to complete updated MDS assessments and baseline care plans. |
| OO | Minimum Data Set Coordinator (MDSC) | Confirmed failure to complete updated MDS assessments. |
| LL | Certified Nurse Assistant (CNA) | Provided information on oxygen and nebulizer equipment supervision and cleaning. |
| MM | Licensed Practical Nurse (LPN) | Provided information on oxygen concentrator monitoring and nebulizer cleaning expectations. |
| D Hall | Unit Manager | Acknowledged improper storage of bedpans and expectations for labeling and bagging. |
| Maintenance Director | Maintenance Director | Confirmed call light system was not functional and described maintenance checks and logs. |
Inspection Report
Original Licensing
Deficiencies: 2
Date: Oct 24, 2024
Visit Reason
A Licensure Survey was conducted from 10/22/2024 through 10/24/2024 to assess compliance with licensure requirements and facility policies.
Findings
The facility failed to ensure proper sanitation and labeling of nebulizers, oxygen concentrator tubing, and bedpans; failed to properly clean and disinfect the medication cart and provide a clean barrier for accu-checks; and failed to provide preventative care consistent with professional standards for a resident at risk for skin breakdown related to repositioning.
Deficiencies (2)
Nebulizers were not bagged, dated, and labeled for two of three residents; oxygen concentrator tubing was undated and filter was dirty for one resident; bedpans were improperly stored unbagged and unlabeled; medication cart was not properly cleaned and no clean barrier was provided for accu-checks.
Preventative care for skin breakdown was inadequate for one resident at risk, with repositioning documented as incomplete.
Report Facts
Repositioning opportunities: 96
Repositioning documented: 59
Sampled residents: 58
Residents with nebulizer issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| D Hall | Unit Manager | Interviewed regarding improper storage of bedpans. |
| MM | Licensed Practical Nurse (LPN) | Interviewed about monitoring and sanitation of oxygen concentrators and nebulizers. |
| MM | Director of Nursing (DON) | Interviewed about expectations for cleaning nebulizers and medication administration. |
| LL | Certified Nurse Assistant (CNA) | Interviewed about supervision and education on oxygen machines and nebulizers. |
Inspection Report
Annual Inspection
Census: 150
Deficiencies: 8
Date: Oct 24, 2024
Visit Reason
A recertification survey was conducted from October 22, 2024 through October 24, 2024, including investigation of multiple substantiated complaints related to abuse and other regulatory compliance issues.
Complaint Details
Complaint Intake Numbers GA 00249231, GA00248869, GA00251060, GA00250242, GA00248615, and GA00250077 were investigated and all were substantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to timely report and thoroughly investigate abuse allegations, incomplete Minimum Data Set (MDS) assessments, lack of baseline care plans, inadequate preventative care for skin breakdown, improper infection control practices, malfunctioning call light system, and failure to maintain antibiotic stewardship documentation.
Deficiencies (8)
Failed to report allegations of sexual abuse timely for two residents.
Failed to complete thorough investigations of abuse for three residents.
Failed to ensure quarterly MDS assessments were completed for two residents.
Failed to complete baseline care plan for one resident with a supra-pubic catheter.
Failed to provide preventative care consistent with professional standards for one resident at risk for skin breakdown related to repositioning.
Failed to ensure proper infection control practices including nebulizer and oxygen concentrator maintenance, bedpan storage, and medication administration procedures.
Failed to maintain review and documentation of antibiotic prescribing practices and stewardship efforts for nine months.
Failed to ensure one resident had a functioning call light system.
Report Facts
Residents present: 150
MDS assessments missed: 2
Repositioning opportunities: 96
Repositioning documented: 59
Months of antibiotic stewardship data missing: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Licensed Practical Nurse (LPN) | Documented abuse incidents involving resident R98 |
| CC | Licensed Practical Nurse (LPN) | Documented abuse incident involving residents R98 and R10 |
| Administrator | Abuse Coordinator responsible for reporting and investigation | |
| DON | Director of Nursing | Responsible for abuse investigations and staff education |
| NN | Minimum Data Set Coordinator/Licensed Practical Nurse (LPN) | Confirmed missing baseline care plan for resident R355 |
| OO | Minimum Data Set Coordinator | Confirmed missing MDS assessment for resident R405 |
| LL | Certified Nurse Assistant (CNA) | Described proper use and cleaning of oxygen machines and nebulizers |
| MM | Licensed Practical Nurse (LPN) | Described monitoring and cleaning of oxygen concentrators and nebulizers |
| D Hall | Unit Manager | Commented on improper storage of bedpans |
| Maintenance Director | Tested and confirmed malfunctioning call light system | |
| Infection Control Preventionist | Described infection control duties and antibiotic stewardship monitoring |
Inspection Report
Life Safety
Census: 151
Capacity: 206
Deficiencies: 3
Date: Oct 23, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically related to the fire alarm system installation and sprinkler system maintenance. Deficiencies included undated fire alarm control panel batteries, a missing sprinkler escutcheon plate in the kitchen, and a spare sprinkler box lacking a sprinkler wrench.
Deficiencies (3)
Fire alarm control panel batteries were not dated with the manufacturer's date.
Sprinkler escutcheon plate missing in the kitchen near the dishwashing area.
Spare sprinkler box did not house a sprinkler wrench.
Report Facts
Smoke compartments affected: 1
Census: 151
Total licensed beds: 206
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire alarm system and sprinkler system deficiencies during facility tour. |
Inspection Report
Re-Inspection
Census: 145
Deficiencies: 0
Date: Aug 23, 2024
Visit Reason
A revisit survey was conducted from 8/22/2024 through 8/23/2024 to verify correction of deficiencies cited during the 6/26/2024 Complaint and Focused Infection Control Survey.
Complaint Details
The revisit survey was related to a complaint investigation conducted on 6/26/2024; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 6/26/2024 Complaint and Focused Infection Control Survey were found to be corrected.
Inspection Report
Routine
Deficiencies: 12
Date: Jun 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility environment, staff qualifications, medication management, infection control, and other aspects of nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to reasonably accommodate resident needs, maintain a safe and clean environment, conduct required background checks, timely report medication misappropriation, develop comprehensive care plans, provide adequate assistance with activities of daily living, administer medications as ordered, ensure staff licensure and certification, maintain infection control standards, and manage pest control effectively.
Deficiencies (12)
Failed to reasonably accommodate the needs and preferences of residents related to wheelchair accessibility and bathing accommodations.
Failed to maintain a safe, clean, and homelike environment including buildup of dirt and grime in air discharge grilles, holes in bathroom and resident rooms, and inadequate linen supply.
Failed to ensure criminal background checks were conducted for two Registered Nurses prior to employment.
Failed to timely report suspected misappropriation of controlled drugs to the State Survey Agency.
Failed to develop and implement comprehensive, person-centered care plans for activities of daily living, falls, fractures, oxygen use, and BiPAP/CPAP for multiple residents.
Failed to provide assistance with activities of daily living to a resident, resulting in uncleanliness and self-consciousness.
Failed to provide appropriate treatment and care according to orders and resident preferences, including pain management, medication administration without physician order, and pest infestation in resident room.
Failed to ensure Certified Nursing Assistants maintained current certification, resulting in two CNAs working with expired certifications.
Failed to ensure one resident was free from unnecessary psychotropic medications, administering Fluoxetine (Prozac) for 48 weeks after discontinuation.
Failed to employ staff with valid licensure, as one Registered Nurse worked with a lapsed license.
Failed to maintain infection control standards by not cleaning and disinfecting reusable items between residents and not performing hand hygiene during medication administration.
Failed to maintain an effective pest control program related to an infestation of black gnats on one unit.
Report Facts
Residents affected: 2
Residents affected: 5
Residents affected: 2
Residents affected: 2
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN GG | Registered Nurse Supervisor | Named in failure to conduct criminal background check |
| RN HH | Registered Nurse Supervisor | Named in failure to conduct criminal background check and lapsed licensure |
| LPN NN | Licensed Practical Nurse | Named in medication administration without physician order and medication pass issues |
| Human Resources Director | Named in failure to conduct background checks and CNA certification renewals | |
| Licensed Practical Nurse RR | Licensed Practical Nurse | Named in medication misappropriation incident |
| Executive Director | Named in multiple interviews regarding facility issues and responses | |
| Assistant Executive Director | Named in interviews regarding facility issues | |
| Environmental Service Director | Named in interviews regarding facility cleanliness and pest control | |
| Maintenance Director QQ | Named in pest control and maintenance interviews | |
| Social Worker YY | Named in resident accommodation interview | |
| Occupational Therapist | Named in interview regarding resident therapy | |
| Pharmacist | Named in interview regarding medication dispensing | |
| Pharmacy Nurse Consultant | Named in medication cart audit interviews | |
| Unit Manager JJ | Named in interviews regarding pest control and medication administration | |
| Certified Nursing Assistant TT | Certified Nursing Assistant | Named in expired certification issue |
| Certified Nursing Assistant UU | Certified Nursing Assistant | Named in expired certification issue |
| Licensed Practical Nurse OO | Licensed Practical Nurse | Named in pest control interview |
| Licensed Practical Nurse LL | Licensed Practical Nurse | Named in pest control interview |
| Unit Manager KK | Named in resident care assistance observation | |
| Unit Manager MM | Named in resident care assistance observation | |
| Certified Nursing Assistant CCC | Certified Nursing Assistant | Named in resident care assistance observation |
| Psychiatrist EEE | Named in medication management interview |
Inspection Report
Routine
Deficiencies: 12
Date: Jun 26, 2024
Visit Reason
The inspection was conducted based on observations, resident and staff interviews, and record reviews to assess compliance with regulatory requirements related to resident care, facility environment, staff qualifications, medication administration, infection control, and pest control.
Findings
The facility was found deficient in multiple areas including failure to reasonably accommodate resident needs, maintain a safe and clean environment, conduct required background checks and licensure verifications, timely report and investigate abuse and medication misappropriation, develop comprehensive care plans, provide adequate assistance with activities of daily living, administer medications as ordered, maintain infection control standards, and manage pest control effectively. Harm was identified related to medication errors and inadequate pain management.
Deficiencies (12)
Failed to reasonably accommodate the needs and preferences of residents related to wheelchair accessibility and bathing accommodations.
Failed to maintain a safe, clean, and comfortable environment including buildup of dirt and grime in air discharge grilles, holes in bathroom and resident rooms, and inadequate linen supply.
Failed to ensure criminal background checks were conducted for two Registered Nurses prior to employment.
Failed to timely report suspected abuse and theft of controlled drugs to the State Survey Agency.
Failed to develop and implement comprehensive, person-centered care plans for activities of daily living, falls, fractures, oxygen use, and BiPAP/CPAP for multiple residents.
Failed to provide assistance with activities of daily living to a resident resulting in uncleanliness and self-consciousness.
Failed to provide appropriate treatment and care according to orders including pain management, medication administration without physician orders, and pest infestation in resident's room. Harm identified related to prolonged administration of discontinued psychotropic medication causing decline in resident condition.
Failed to ensure Certified Nursing Assistant certifications were renewed timely, resulting in staff working with expired certifications.
Failed to employ staff with valid licensure as one Registered Nurse was hired with a lapsed license.
Failed to maintain infection control standards by not cleaning and disinfecting reusable items between residents and not performing hand hygiene during medication administration.
Failed to obtain vaccination consent before administering COVID-19 vaccines to residents.
Failed to maintain an effective pest control program related to infestation of black gnats on one unit.
Report Facts
Residents affected: 2
Residents affected: 5
Residents affected: 2
Residents affected: 2
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN GG | Registered Nurse Supervisor | Named in finding for failure to conduct criminal background check |
| RN HH | Registered Nurse Supervisor | Named in finding for failure to conduct criminal background check and lapsed licensure |
| LPN NN | Licensed Practical Nurse | Named in medication administration and pain management findings |
| LPN RR | Licensed Practical Nurse | Named in medication misappropriation finding |
| Human Resources Director | Human Resources Director | Named in findings related to background checks and CNA certification renewals |
| Executive Director | Executive Director | Named in multiple findings including background checks, medication errors, and pest control |
| Occupational Therapist | Occupational Therapist | Named in finding related to resident hand braces and pain |
| Wound Care Physician | Wound Care Physician | Named in finding related to wound care and pest infestation |
| Pharmacist | Pharmacist | Named in medication dispensing and reconciliation findings |
| Psychiatrist EEE | Psychiatrist | Named in medication management and psychotropic medication findings |
| Unit Manager JJ | Unit Manager | Named in findings related to pest control and resident care |
| Registered Nurse SS | Registered Nurse | Named in infection control and medication administration findings |
| Certified Nursing Assistant CCC | Certified Nursing Assistant | Named in ADL assistance finding |
| Certified Nursing Assistant TT | Certified Nursing Assistant | Named in CNA certification renewal finding |
| Certified Nursing Assistant UU | Certified Nursing Assistant | Named in CNA certification renewal finding |
| Licensed Practical Nurse OO | Licensed Practical Nurse | Named in pest control finding |
| Licensed Practical Nurse LL | Licensed Practical Nurse | Named in pest control finding |
| Social Worker YY | Social Worker | Named in resident accommodation finding |
Inspection Report
Complaint Investigation
Census: 150
Deficiencies: 13
Date: Jun 26, 2024
Visit Reason
A Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended survey investigating multiple complaints initiated on 2024-05-02 and concluded on 2024-06-26.
Complaint Details
The survey was initiated based on multiple complaint numbers including GA00236153, GA00236989, GA00238550, GA00238994, GA00239097, GA00239261, GA00239810, GA00241715, GA00241717, GA00243898, GA00244895, GA00246253, GA00247484, and GA00247622. Some complaints were substantiated with deficiencies, others were unsubstantiated or substantiated with no deficiencies.
Findings
The facility was found not in compliance with infection control regulations, with harm identified related to medication errors and pest infestation. Deficiencies were found in reasonable accommodations, safe environment, staff background checks, complaint reporting, care planning, ADL care, medication administration, staff licensure, infection control, COVID-19 vaccination consent, and pest control.
Deficiencies (13)
Failure to provide reasonable accommodations for residents related to wheelchair accessibility and bathing preferences.
Failure to maintain a safe, clean, and comfortable environment including dirt buildup in air discharge grilles, holes in bathroom and resident rooms, and inadequate linen supply.
Failure to conduct criminal background checks for two registered nurses prior to employment.
Failure to report misappropriation of controlled drugs to the State Survey Agency.
Failure to develop comprehensive, person-centered care plans for multiple residents including ADLs, falls, fractures, oxygen use, and BiPAP/CPAP.
Failure to provide ADL care assistance to a resident resulting in unclean appearance and unmet hygiene needs.
Failure to provide adequate nursing care related to pain management, medication administration without physician order, and pest infestation in resident's room.
Failure to ensure timely renewal of CNA certifications resulting in staff working with expired certifications.
Failure to ensure resident was free from unnecessary psychotropic medication; Fluoxetine was administered for 48 weeks after discontinuation.
Failure to ensure staff licensure was current; RN worked with lapsed license.
Failure to maintain infection control standards including cleaning and disinfecting reusable items between residents and performing hand hygiene during medication administration.
Failure to obtain vaccination consent before administering COVID-19 vaccines to residents.
Failure to maintain an effective pest control program related to infestation of black gnats on one unit.
Report Facts
Residents present: 150
Pain level: 7
Medication administration count: 57
Medication administration count: 5
CNA certification lapse duration: 6
CNA certification lapse duration: 1
RN worked with lapsed license: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN HH | Registered Nurse Supervisor | Worked with lapsed RN license |
| CNA TT | Certified Nursing Assistant | Worked 6 months with expired certification |
| CNA UU | Certified Nursing Assistant | Worked 1 month with expired certification |
| LPN NN | Licensed Practical Nurse | Administered Fluoxetine (Prozac) without physician order |
| Human Resources Director | Responsible for hiring and license verification | |
| Psychiatrist EEE | Psychiatrist | Discontinued Fluoxetine (Prozac) and prescribed alternative |
| Pharmacist | Confirmed pharmacy dispensed discontinued medication | |
| Maintenance Director QQ | Maintenance Director | Oversees pest control program |
| Unit Manager JJ | Unit Manager | Reported pest infestation |
| Director of Health Services | Oversight of nursing and infection control | |
| RN SS | Registered Nurse | Failed to clean equipment and perform hand hygiene |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 9, 2023
Visit Reason
An Abbreviated Partial Extended survey was conducted to investigate complaints #GA00233964, #GA00233533, #GA00233350, and #GA00232277.
Complaint Details
Complaints #GA00233964, #GA00233533, #GA00233350, and #GA00232277 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 147
Deficiencies: 0
Date: Feb 9, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated Survey investigating complaints #GA00229051, #GA00230754, and #GA00230883 was conducted.
Complaint Details
Complaints #GA00229051, #GA00230754, and #GA00230883 were investigated and found to be unsubstantiated.
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and implemented CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 147
Inspection Report
Deficiencies: 0
Date: Feb 9, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Sadie G. Mays Health & Rehabilitation Center, summarizing the findings of a regulatory survey completed on 2023-02-09.
Findings
No health deficiencies were found during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 15, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Sadie G. Mays Health & Rehabilitation Center following a survey completed on 11/15/2022.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 143
Deficiencies: 0
Date: Nov 15, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 19, 2022 Recertification with Complaints Survey.
Findings
All deficiencies cited in the prior August 19, 2022 survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 17, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the Follow-Up Survey.
Inspection Report
Routine
Deficiencies: 4
Date: Aug 19, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, respiratory care, medication administration, and medication storage at Sadie G. Mays Health & Rehabilitation Center.
Findings
The facility was found deficient in maintaining resident privacy due to missing privacy curtains, failing to follow physician orders for oxygen administration for two residents, medication errors resulting in a 7.4% error rate, and failure to keep medication carts securely locked at all times.
Deficiencies (4)
Failed to provide a privacy curtain to ensure personal privacy for two of 45 sampled residents.
Failed to follow physician orders related to oxygen administration for two residents reviewed with oxygen.
Failed to maintain a medication error rate of 5% or less; observed 7.4% medication error rate with two errors out of 27 opportunities.
Failed to maintain a secure, locked medication cart for one out of six medication carts.
Report Facts
Residents sampled: 45
Medication error rate: 7.4
Medication error count: 2
Medication opportunities: 27
Medication carts: 6
Medication carts unsecured: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN VV | Licensed Practical Nurse | Named in medication error finding for administering chewable aspirin instead of enteric coated |
| LPN JJ | Licensed Practical Nurse | Named in medication error finding for forgetting to apply diclofenac ointment |
| LPN TT | Licensed Practical Nurse | Named in medication cart security deficiency and oxygen monitoring |
| Director of Nursing | Director of Nursing | Provided expectations on privacy curtains, oxygen monitoring, medication administration, and medication cart security |
| Administrator | Administrator | Provided expectations on privacy curtains, oxygen monitoring, medication administration, and medication cart security |
| Unit Manager GG | Unit Manager | Interviewed regarding oxygen orders and monitoring |
Inspection Report
Renewal
Deficiencies: 3
Date: Aug 19, 2022
Visit Reason
A Licensure Survey was conducted from 8/15/22 through 8/19/22 to assess compliance with licensure requirements for Sadie G. Mays Health & Rehabilitation Center.
Findings
The survey identified deficiencies including failure to provide privacy curtains for two residents, failure to maintain a secure locked medication cart, and a medication error rate exceeding 5% due to incorrect administration and missed application of medications.
Deficiencies (3)
Facility failed to provide a privacy curtain to ensure personal privacy for two of 45 sampled residents (R#16 and R#47).
Facility failed to maintain a secure, locked medication cart for one out of six medication carts.
Facility failed to maintain a medication error rate of 5% or less, with two errors out of 27 opportunities observed during medication pass for two residents (R#105 and R#106).
Report Facts
Residents sampled: 45
Medication carts: 6
Medication error rate: 7.4
Medication errors: 2
Medication opportunities: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN SS | Licensed Practical Nurse | Observed walking past unlocked medication cart and locking it |
| LPN TT | Licensed Practical Nurse | Observed leaving medication cart unlocked and behind curtain with resident |
| LPN UU | Licensed Practical Nurse | Interviewed about medication cart locking policy |
| LPN VV | Licensed Practical Nurse | Administered chewable aspirin instead of enteric coated aspirin |
| LPN JJ | Licensed Practical Nurse | Failed to apply diclofenac cream as ordered during medication administration |
| Director of Nursing | Director of Nursing | Provided expectations regarding privacy curtains and medication cart security |
| Administrator | Administrator | Provided expectations regarding privacy curtains and medication administration |
| Maintenance Director | Maintenance Director | Reported on privacy curtain track repair and reinstallation |
| Laundry Aide WW | Laundry Aide | Provided information about responsibility for hanging privacy curtains |
Inspection Report
Routine
Census: 142
Deficiencies: 4
Date: Aug 19, 2022
Visit Reason
A standard survey was conducted from August 15, 2022 through August 19, 2022, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Complaint Details
Complaint Intake Numbers GA00219180, GA00220142, GA00220212, GA00221658, GA00222055, GA00223943, GA00224349 were investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide privacy curtains for residents, failure to follow physician orders for oxygen administration, medication errors exceeding 5%, and unsecured medication carts.
Deficiencies (4)
Failed to provide a privacy curtain to ensure personal privacy for two residents.
Failed to follow physician orders related to oxygen administration for two residents.
Failed to maintain a medication error rate of 5% or less; two errors out of 27 opportunities (7.4% error rate).
Failed to maintain a secure, locked medication cart; observed unlocked and unattended medication carts.
Report Facts
Resident census: 142
Medication error rate: 7.4
Medication error count: 2
Medication administration opportunities: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN VV | Licensed Practical Nurse | Administered chewable aspirin instead of enteric coated aspirin |
| LPN JJ | Licensed Practical Nurse | Forgot to apply diclofenac cream during medication administration |
| LPN SS | Licensed Practical Nurse | Observed medication cart unlocked and locked it |
| LPN TT | Licensed Practical Nurse | Observed with unlocked medication cart outside resident room |
| Director of Nursing | Director of Nursing | Stated expectation that medication carts be locked at all times and privacy curtains be maintained |
| Administrator | Administrator | Stated expectation that medication carts be secure and privacy curtains be replaced promptly |
Inspection Report
Routine
Census: 144
Capacity: 206
Deficiencies: 6
Date: Aug 16, 2022
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Program, Life Safety Code compliance, and related regulatory requirements.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements, including lack of documentation for emergency exercises and plan updates, and deficiencies in fire alarm system readiness, sprinkler system maintenance, electrical safety, and emergency power system testing.
Deficiencies (6)
No documentation available that the emergency preparedness plan included an organized full size or tabletop exercise and no physical record of training or documented 'after action' reports of any exercises.
No documentation available showing that the emergency preparedness plan had been updated or approved in the last year.
Facility fire alarm system was in trouble and silenced, affecting 1 of 4 smoke compartments.
Fire sprinkler system 5-year inspection, testing, and maintenance was overdue by several months; missing sprinkler escutcheon plate near back door.
Therapy tools (walkers) placed in front of electrical panel box and Multiple Outlet Power Supply device located on the floor in therapy center, creating electrical hazards.
Emergency backup power system 4-hour load test required every three years was overdue.
Report Facts
Census: 144
Total Capacity: 206
Date of Survey: Aug 16, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A and Staff M confirmed findings related to emergency preparedness plan documentation and exercise deficiencies. | ||
| Staff M | Confirmed findings related to fire alarm system trouble, sprinkler system deficiencies, electrical hazards, and emergency power system testing. |
Inspection Report
Abbreviated Survey
Census: 140
Deficiencies: 0
Date: Aug 30, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted in conjunction with a COVID-19 Focused Infection Control Survey to investigate multiple complaints and assess compliance with infection control regulations.
Complaint Details
Complaint #GA00216442 was unsubstantiated. Complaints #GA00216097, #GA00215471, #GA00215114, #GA00214588, #GA00213623, and #GA00212558 were substantiated with no deficiencies.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control. One complaint was unsubstantiated, and several complaints were substantiated with no deficiencies identified.
Report Facts
Resident Census: 140
Inspection Report
Abbreviated Survey
Census: 148
Deficiencies: 0
Date: Feb 9, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted along with an Abbreviated/Partial Extended Survey investigating complaint numbers GA00211743 and GA00209935.
Complaint Details
Complaint #GA00211743 was substantiated with no regulatory violations cited. Complaint #GA00209935 was unsubstantiated with no regulatory violations cited.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended COVID-19 practices. Complaint #GA00211743 was substantiated with no regulatory violations cited, and complaint #GA00209935 was unsubstantiated with no violations cited.
Report Facts
Total census: 148
Inspection Report
Deficiencies: 0
Date: Dec 22, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Sadie G. Mays Health & Rehabilitation Center following a survey completed on December 22, 2020.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 154
Deficiencies: 0
Date: Dec 22, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited as a result of the 10/29/2020 Complaint and COVID-19 Infection Control Survey.
Complaint Details
The revisit survey was conducted following a complaint investigation dated 10/29/2020.
Findings
All deficiencies cited in the prior complaint and COVID-19 infection control survey were found to be corrected during this revisit survey.
Report Facts
Census: 154
Inspection Report
Original Licensing
Deficiencies: 3
Date: Oct 29, 2020
Visit Reason
A Licensure Survey was conducted from 10/26/2020 through 10/29/2020 to assess compliance with licensure requirements for the facility.
Findings
The facility was found deficient in notifying the resident's responsible party of significant changes in condition, failure to follow transmission-based precautions on the COVID-19 isolation unit, and failure to maintain an effective pest control program with inadequate cleaning of soiled utility rooms.
Deficiencies (3)
Failure to notify the resident's Responsible Party (legal guardian) of a significant change in condition for Resident #3.
Failure to follow transmission-based precautions prior to entering and exiting the Level II COVID-19 isolation unit, including improper use of PPE by staff and transporters.
Failure to maintain an effective pest control program, including failure to clean and maintain three of four soiled utility rooms as recommended by pest control service provider.
Report Facts
Residents on Level II unit: 11
Dates of Licensure Survey: Survey conducted from 2020-10-26 through 2020-10-29.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LL | Social Worker | Interviewed regarding Resident #3's legal guardian and notification requirements. |
| DHS | Director of Health Services | Interviewed regarding notification procedures and PPE requirements on Level II unit. |
| VV | Licensed Practical Nurse | Interviewed regarding notification of Responsible Party. |
| LL | Licensed Practical Nurse | Interviewed regarding notification of Responsible Party. |
| Licensed Practical Nurse | Observed and interviewed regarding PPE use and transport procedures on Level II unit. | |
| Employee II | Charge Nurse B-Hall | Interviewed regarding pest control issues and reporting. |
| Assistant Administrator | Interviewed regarding pest control service scheduling and communication. | |
| Environmental Director | Interviewed and observed regarding soiled utility rooms and pest control. |
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 4
Date: Oct 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with investigations of multiple complaint intake numbers related to infection control and COVID-19 preparedness.
Complaint Details
Complaints #GA00205731, #GA00205019, #GA00204557, #GA00205619, #GA00205194, #GA00208808 were unsubstantiated. Complaints #GA00206402, #GA00205849, and #GA00206480 were substantiated with deficiencies related to infection control and COVID-19 preparedness.
Findings
The facility was found not in compliance with infection control regulations and failed to implement CMS and CDC recommended practices for COVID-19. Several deficiencies were identified including failure to notify resident representatives of condition changes, failure to follow physician orders for weekly weights, failure to follow transmission-based precautions on a COVID-19 isolation unit, and failure to maintain an effective pest control program.
Deficiencies (4)
Failure to notify resident's Responsible Party (legal guardian) of a significant change in condition for Resident #3.
Failure to follow physician's orders for weekly weights for Resident #7, resulting in significant unmonitored weight loss.
Failure to follow transmission-based precautions on the Level II COVID-19 Person Under Investigation unit, including improper use of PPE by staff and transporters.
Failure to maintain an effective pest control program; soiled utility rooms were unclean with overflowing trash, flying insects, rodent traps obstructed, and structural damage.
Report Facts
Total census: 140
Weight loss percentage: 19
Number of residents on Level II unit: 11
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 10, 2020
Visit Reason
The survey was initiated by desk review to investigate infection control concerns from multiple complaint investigations between April 21, 2020 and May 4, 2020, followed by onsite Covid-19 focused infection control survey and further onsite observations to address all allegations.
Complaint Details
The survey investigated multiple complaints related to infection control concerns. The complaints were not substantiated.
Findings
No findings of harm or immediate jeopardy were identified during desk reviews or onsite visits. The complaints were not substantiated and no regulatory violations were cited throughout the abbreviated/partial extended survey process.
Inspection Report
Routine
Census: 152
Deficiencies: 0
Date: Jun 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 152
Deficiencies: 0
Date: Jun 18, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00203901, GA00203912, and GA00203971, and a COVID-19 Focused Infection Control Survey was conducted on June 18, 2020.
Complaint Details
Complaints GA00203901 and GA0020371 were partially substantiated with no deficiencies; complaint GA00203912 was unsubstantiated.
Findings
Complaints GA00203901 and GA0020371 were partially substantiated with no deficiencies, complaint GA00203912 was unsubstantiated, and no deficiencies were cited during the COVID-19 Focused Infection Control Survey.
Report Facts
Total census: 152
Inspection Report
Deficiencies: 0
Date: Feb 25, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Sadie G. Mays Health & Rehabilitation Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 188
Deficiencies: 0
Date: Feb 25, 2020
Visit Reason
A revisit survey was conducted from 2/24/2020 through 2/26/2020 to investigate complaint intake numbers GA00202902 and GA00203091 and to verify correction of deficiencies cited in the 12/23/19 complaint survey.
Complaint Details
Complaint intake numbers GA00202902 and GA00203091 were investigated and found to be unsubstantiated with no deficiencies.
Findings
All deficiencies cited as a result of the 12/23/19 complaint survey were found to be corrected. The complaint investigation found GA00202902 and GA00203091 to be unsubstantiated with no deficiencies.
Report Facts
Facility census: 188
Inspection Report
Re-Inspection
Census: 188
Deficiencies: 0
Date: Feb 25, 2020
Visit Reason
A revisit survey was conducted on 2/26/2020 to investigate Complaint Intake Numbers GA00202902 and GA00203091 in conjunction with this revisit survey.
Complaint Details
Complaint Intake Numbers GA00202902 and GA00203091 were investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the 12/23/19 complaint survey were found to be corrected. The complaint investigation found both complaints unsubstantiated.
Report Facts
Facility census: 188
Inspection Report
Complaint Investigation
Census: 184
Deficiencies: 0
Date: Jan 17, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00202186 and GA00201806 and to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaints GA00202186 and GA00201806 were investigated and found to be unsubstantiated.
Findings
The complaints were found to be unsubstantiated and the facility was in substantial compliance with the applicable requirements.
Report Facts
Resident Census: 184
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 23, 2019
Visit Reason
The inspection was conducted as a complaint survey to investigate alleged deficiencies at the facility.
Complaint Details
The complaint survey found no licensure deficiencies; no substantiation of complaints was noted.
Findings
No licensure deficiencies were identified during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 12, 2019
Visit Reason
A complaint survey was conducted from 2019-06-10 to 2019-06-12 to investigate complaints #GA00196993 and #GA00196006 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted to investigate complaints #GA00196993 and #GA00196006; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Census: 187
Deficiencies: 0
Date: Jun 12, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey conducted on 2019-04-19.
Findings
All deficiencies cited in the prior Recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 4, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during this Follow-Up Survey.
Inspection Report
Complaint Investigation
Census: 194
Deficiencies: 12
Date: Apr 19, 2019
Visit Reason
The inspection was conducted based on complaints and concerns related to residents' rights, care, safety, and facility conditions including voting rights, shower accommodations, advance directives, environment safety, restraint use, care planning, restorative services, smoking supervision, food safety, and infection control.
Complaint Details
The visit was complaint-related, triggered by allegations concerning residents' rights violations, inadequate care, unsafe environment, improper use of restraints, incomplete care planning, lack of restorative services, inadequate supervision during smoking, food safety issues, and infection control deficiencies.
Findings
The facility was found deficient in multiple areas including failure to allow a resident to exercise voting rights, failure to provide scheduled showers due to lack of appropriate equipment, failure to provide written evidence of advance directive information, unsafe and unsanitary environment conditions, improper use of physical restraints, incomplete baseline and comprehensive care plans, failure to provide restorative nursing services consistently, inadequate supervision during smoking breaks, food safety violations including improper food storage and sanitation, and failure to maintain infection control related to labeling and storage of personal care equipment.
Deficiencies (12)
Failed to allow one resident to exercise their right to vote in the November 2018 election.
Failed to provide scheduled showers for six residents due to lack of functional reclining shower chair or trolley.
Failed to provide written evidence that one resident was given information on and opportunity to formulate an advance directive.
Failed to maintain a safe, clean, comfortable and homelike environment in eight resident rooms and dining room ceiling tiles.
Failed to ensure one resident was free from physical restraints; resident observed with seatbelt restraint without assessment or evaluation.
Failed to complete a baseline care plan for one resident within 48 hours of admission.
Failed to develop and implement complete care plans for residents related to smoking, activities of daily living, and range of motion.
Failed to provide care and assistance for activities of daily living for one resident related to nail care.
Failed to provide appropriate restorative nursing services consistently for two residents related to splinting and range of motion.
Failed to provide adequate supervision during smoking breaks for two residents who were observed with smoking materials in their possession and staff assisted in lighting cigarettes.
Failed to ensure opened food items in dry storage and coolers were labeled and dated; failed to discard food items by expiration date; failed to maintain sanitary kitchen conditions including wet cookware stacking, three compartment sink sanitation, dish machine temperature, and hair net use; failed to maintain sanitary resident diet pantries and proper food holding temperatures.
Failed to maintain an effective infection control program related to labeling and storage of residents' personal care equipment in four resident rooms.
Report Facts
Residents affected: 1
Residents affected: 6
Residents affected: 1
Residents affected: 8
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 2
Facility census: 194
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Social Worker (SW) | Failed to register resident to vote and did not inform resident |
| Administrator | Administrator | Confirmed voting rights deficiency and absentee ballot issue |
| Director of Health Service | Director of Health Service (DHS) | Confirmed voting rights deficiency and shower chair issues |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) MM | Reported shower chair issues and restorative nursing documentation problems |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) NN | Reported shower chair issues |
| Maintenance Director | Maintenance Director | Reported broken shower chairs and maintenance issues |
| Social Services | Social Services HH | Discussed advance directives with residents |
| Resident Nurse Consultant | Resident Nurse Consultant | Interviewed about restraint use on resident |
| Unit Manager | Unit Manager BB | Discussed baseline care plan and resident care needs |
| Case Mix Coordinator | Registered Nurse Case Mix Coordinator VV | Discussed MDS assessments and restorative nursing coding |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) AA | Reported resident nail care issues |
| Dietary | Dietary [NAME] DD | Reported kitchen sanitation and food storage issues |
| Dietary Aide | Dietary Aide FF | Observed dish machine operation |
| Dietary Aide | Dietary Aide XX | Observed not wearing hair net during meal prep |
| Infection Control Nurse | Infection Control Nurse | Discussed labeling and storage of personal care equipment |
| Assistant Director of Health Services | Assistant Director of Health Services (ADHS) | Discussed smoking supervision and restorative nursing program |
Inspection Report
Routine
Census: 194
Deficiencies: 11
Date: Apr 19, 2019
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations and requirements for long term care facilities.
Findings
The survey identified multiple deficiencies including failure to allow a resident to exercise voting rights, failure to provide scheduled showers due to lack of functional shower chairs, failure to provide written evidence of advance directive information, unsafe and unsanitary environment conditions, use of physical restraints without proper assessment, inaccurate assessments, incomplete baseline and comprehensive care plans, failure to provide adequate ADL care, failure to provide restorative services for range of motion, inadequate supervision during smoking breaks, food safety violations, and infection control issues related to labeling and storage of personal care equipment.
Deficiencies (11)
Facility failed to allow one resident to exercise their right to vote in the November 2018 election.
Facility failed to provide scheduled showers for six residents due to lack of functional reclining shower chairs or trolleys.
Facility failed to provide written evidence that one resident was given information on and opportunity to formulate an advance directive.
Facility failed to maintain a safe, clean, comfortable, and homelike environment in eight resident rooms and dining room ceiling tiles.
Facility failed to ensure one resident was free from physical restraints; resident was observed with a seatbelt restraint without assessment or monitoring.
Facility failed to ensure accuracy of assessments for three residents related to PASRR Level II status, restorative nursing program, and use of restraints.
Facility failed to complete a baseline care plan for one resident and failed to develop comprehensive care plans addressing key needs for three residents.
Facility failed to provide restorative services for splinting and range of motion consistently for two residents.
Facility failed to provide adequate supervision during smoking breaks for two residents who had smoking materials in their possession and staff assisted in lighting cigarettes.
Facility failed to ensure food safety including proper labeling and dating of opened food items, sanitary kitchen conditions, proper sanitizing in dishwashing, and proper food holding temperatures.
Facility failed to maintain an effective infection control program related to labeling and storage of residents' personal care equipment in four resident rooms.
Report Facts
Resident census: 194
Restorative nursing documentation missing days: 62
Dishwasher sanitizing solution ppm: 0
Dishwasher sanitizing solution ppm: 300
Hot food temperature: 50
Cold food temperature: 55
Cold food temperature: 45
Refrigerator temperature: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PP | Certified Nursing Assistant | Supervising residents during smoke break and failed to report residents with cigarettes in possession |
| DD | Dietary Cook | Observed with opened and undated food items in walk-in cooler and kitchen |
| EE | Dietary Cook | Observed improper use of three-compartment sink and failure to wear hair net |
| UU | Restorative Nursing Assistant | Responsible for applying splints and documenting restorative services but failed to document many days |
| BBB | Licensed Practical Nurse | Responsible for oversight of restorative nursing program but unable to ensure documentation |
| MM | Licensed Practical Nurse Unit Manager | Verified unsanitary resident pantry and assigned cleaning duties |
| ZZ | Registered Nurse Unit Manager | Verified unsanitary resident pantry and assigned cleaning duties |
| Infection Control Nurse | Conducts daily rounds to check for proper labeling and storage of personal care equipment | |
| ADHS | Assistant Director of Health Services | Responsible for smoking program and restorative nursing program oversight |
Inspection Report
Routine
Deficiencies: 7
Date: Apr 19, 2019
Visit Reason
Routine inspection of Sadie G. Mays Health & Rehabilitation Center to assess compliance with healthcare facility regulations including infection control, nursing care, safety, environmental sanitation, and physical plant standards.
Findings
The inspection identified multiple deficiencies including improper infection control practices with unbagged and unlabeled resident care equipment, failure to follow smoking supervision policies, inadequate nursing care per care plans, improper use and monitoring of restraints, safety hazards in the facility, unsanitary environmental conditions, and food safety violations in the kitchen and resident pantries.
Deficiencies (7)
Unbagged and unlabeled bedpans, urinals, and bath basins found in resident bathrooms and rooms.
Resident observed smoking with unauthorized cigarettes and staff failed to intervene or report violation of smoking policy.
Resident care plans not followed including failure to provide assistance with grooming and use of splints as ordered.
Physical restraint used without physician order or assessment; resident unable to self-release seatbelt restraint.
Multiple safety hazards including loose electrical jack, dirty air conditioner vents, stained ceiling tiles, broken furniture, and debris from maintenance work.
Food safety violations including raw chicken soaking without running water, undated and unsealed food items in walk-in cooler, inadequate sanitizing solution in dishwashing sink, improper food temperatures, and unclean resident pantries with expired and unlabeled food.
Dietary staff observed not wearing required hair restraint in food preparation area.
Report Facts
Deficiencies cited: 7
BIMS score: 13
BIMS score: 99
Sanitizer concentration: 0
Sanitizer concentration: 50
Sanitizer concentration: 300
Food temperature: 50
Food temperature: 55
Food temperature: 45
Dishwasher wash cycle temperature: 167
Dishwasher rinse cycle temperature: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PP | Certified Nursing Assistant | Supervised smoking break where resident was observed with unauthorized cigarettes and failed to intervene or report. |
| AA | Certified Nursing Assistant | Verified resident's nails were dirty and long; described duties including grooming and bathing. |
| BB | Unit Manager | Verified expectations for staff to provide grooming and nail care; acknowledged resident refusal of care. |
| UU | Restorative Nursing Assistant | Responsible for applying/removing splint; last applied splint on 3/30/19 but forgot to document. |
| RR | Staff | Reported resident with contractures not receiving restorative services after discharge from OT. |
| Resident Nurse Consultant | Stated resident could sometimes release restraint belt; no assessment done for restraint use. | |
| DD | Dietary Cook | Observed food safety violations in kitchen including raw chicken soaking and undated food items. |
| EE | Dietary Cook | Observed improper sanitizing solution levels and food temperatures; stated dishwasher technician visited. |
| FF | Dietary Aide | Observed improperly loading dish machine and rewashed trays. |
| MM | Unit Manager Licensed Practical Nurse | Verified concerns in resident pantry and cleaning responsibilities. |
| ZZ | Unit Manager Registered Nurse | Verified pantry cleaning responsibilities and procedures. |
| XX | Dietary Aide | Observed not wearing hair net or beard covering during food preparation. |
Inspection Report
Life Safety
Census: 193
Capacity: 206
Deficiencies: 2
Date: Apr 4, 2019
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety and related National Fire Protection Association (NFPA) standards for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with the Life Safety Code requirements, specifically regarding smoke barrier construction and utilities safety. Deficiencies included penetrations in smoke/fire barriers above ceilings and blocked access to electrical panels, which could place residents and staff at risk.
Deficiencies (2)
Smoke barriers above ceilings at rated walls had penetrations at smoke doors in the A-Hall and D-Hall, compromising smoke resistance.
Blocked access to an electrical panel in the kitchen due to a rack and presence of a multi-outlet power supply under a table in the marketing office, risking electrical shock.
Report Facts
Residents at risk: 100
Staff at risk: 6
Census: 193
Total capacity: 206
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 12, 2019
Visit Reason
A complaint survey was conducted to investigate complaints #GA00195049 and determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00195049 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 12, 2019
Visit Reason
A complaint survey was conducted to investigate complaint GA00193780 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00193780 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 27, 2018
Visit Reason
A complaint survey was conducted from 12/19/18 to 12/26/18 to investigate complaints GA00192617 and GA00193378 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted to investigate complaints GA00192617 and GA00193378; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 27, 2018
Visit Reason
A desk revisit survey was conducted to verify correction of deficiencies cited during the complaint investigation survey on 2018-07-06.
Complaint Details
This visit was a follow-up to a complaint investigation survey conducted on 2018-07-06.
Findings
All deficiencies cited as a result of the complaint investigation survey on 2018-07-06 were found to be corrected.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 6, 2018
Visit Reason
A complaint survey was conducted to investigate an allegation of abuse involving a fractured left knee of Resident #1, to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The complaint investigation was triggered by allegation GA00189740 regarding abuse causing a fractured left knee of Resident #1. The allegation was substantiated as the facility admitted to missing the two-hour reporting window and initiated an investigation. The involved CNAs were suspended.
Findings
The facility failed to report the alleged abuse causing the fractured left knee to the State Survey Agency within the required two-hour timeframe. Resident #1 was found to have a fractured left distal femur and tibia, and the facility delayed reporting the incident by two days. The involved CNAs were suspended pending investigation.
Deficiencies (1)
Failure to report alleged abuse involving a fractured left knee within the required two-hour timeframe.
Report Facts
Sample size: 3
Reporting delay: 2
BIMS score: 7
Incident date: Jun 29, 2018
Incident report date: Jul 2, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Accepted responsibility for missing the two-hour reporting window and initiated investigation |
| RN FF | Nursing Consultant | Confirmed corporate policy requires reporting suspected abuse within two hours and affirmed delay in reporting |
| Assistant Administrator | Assistant Administrator | Interviewed and stated lack of knowledge about two-hour reporting requirement |
Inspection Report
Re-Inspection
Census: 175
Deficiencies: 0
Date: Apr 19, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 3/1/18 Recertification survey.
Findings
All deficiencies cited as a result of the 3/1/18 Recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 19, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 13, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00186052.
Complaint Details
The complaint was substantiated with no deficiencies cited.
Findings
The complaint was substantiated but no deficiencies were cited during the survey.
Inspection Report
Routine
Census: 180
Deficiencies: 5
Date: Mar 1, 2018
Visit Reason
A standard survey was conducted from February 26, 2018 through March 1, 2018, including investigation of complaint intake numbers GA00185633 and GA00185664, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Numbers GA00185633 and GA00185664 were investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inaccurate resident assessments, failure to develop and implement comprehensive care plans for toileting programs, failure to provide scheduled showers for dependent residents, failure to provide services to maintain or restore bowel and bladder continence, and improper storage and labeling of medications including expired drugs.
Deficiencies (5)
Inaccurate Minimum Data Set (MDS) assessments for Resident #145, incorrectly identifying a diagnosis of schizophrenia requiring a Level II PASARR screening that was not completed.
Failure to develop and implement toileting programs for residents incontinent of bowel and/or bladder (Residents #38, #105, #165, #127).
Failure to provide scheduled showers for Resident #127, who was dependent on staff for bathing and personal hygiene, missing 5 scheduled showers in February 2018.
Failure to provide services to maintain or restore bowel and bladder continence for Residents #38, #105, #127, and #165, including lack of toileting programs and inadequate incontinence care.
Failure to remove expired medications and improper storage of medications on four medication carts, including expired drugs and mixing of medications with different routes of administration in the same compartments.
Report Facts
Resident census: 180
Sample size: 34
Scheduled showers missed: 5
Expired medication dates: 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN CC | Licensed Practical Nurse, Unit Manager for D Wing | Confirmed expired medications and improper medication storage; stated residents #38, #165, #127 had never been assessed for bowel and bladder retraining program |
| RN Acting Director of Nursing | Registered Nurse | Confirmed medication storage deficiencies and stated all residents should be assessed for toileting programs |
| CNA BB | Certified Nursing Assistant | Assigned to Resident #38; stated no toileting program was directed and confirmed delayed incontinence care |
| LPN FF | Licensed Practical Nurse | Stated restorative department responsible for toileting program assessments |
| RN M | Registered Nurse | Stated Resident #105 was incontinent and not on toileting program |
| LPN BB | Licensed Practical Nurse | Confirmed missing expiration date on aspirin bottle in medication cart |
| LPN DD | Licensed Practical Nurse | Confirmed improper medication storage mixing ointments with oral medications |
| LPN EE | Licensed Practical Nurse | Confirmed expired glucose testing solution and improper medication storage |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 1, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, and toileting programs, including review of Minimum Data Set (MDS) assessments and care plans for residents with incontinence issues.
Findings
The facility failed to ensure accurate resident assessments, as evidenced by incorrect diagnosis coding for one resident (R#145) leading to missing required screenings. Additionally, the facility did not develop or implement toileting programs for four of five sampled residents who were incontinent, resulting in inadequate management of bowel and bladder incontinence and potential risk to a larger resident population.
Deficiencies (2)
Incorrect diagnosis of schizophrenia for Resident #145 on multiple MDS assessments without required Level II PASARR screening.
Failure to develop, revise, and implement toileting programs for residents incontinent of bowel and/or bladder (Residents #38, #105, #127, #165).
Report Facts
MDS assessments with incorrect diagnosis: 6
Residents sampled for toileting program deficiency: 4
Residents potentially affected by toileting program failure: 149
Residents potentially affected by toileting program failure: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Nursing Assistant | Assigned to Resident #38; reported no toileting direction and delayed incontinence care. |
| FF | Licensed Practical Nurse | Unit A nurse's station; discussed toileting program assessments and restorative referrals. |
| CC | Licensed Practical Nurse | Unit Manager for D wing; stated residents #38, #165, #127 not assessed for toileting programs. |
| M | Registered Nurse Acting Director of Nursing | Confirmed residents should be assessed for toileting programs and toileting offered every two hours. |
| LVN | Certified Nursing Assistant | Reported Resident #105 mostly self-care but occasional accidents requiring cleanup. |
| Director of Social Services | Confirmed no Level II PASARR screening completed for Resident #145. | |
| MDS coordinator | Acknowledged coding error for schizophrenia diagnosis on Resident #145 MDS assessments. |
Inspection Report
Life Safety
Census: 180
Capacity: 206
Deficiencies: 4
Date: Feb 26, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and Medicare/Medicaid participation requirements.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain optimum readiness of the fire sprinkler system, improper operation of corridor and smoke barrier doors, failure of fire doors to latch during alarm activation, and the presence of prohibited portable space heaters.
Deficiencies (4)
Loaded sprinkler heads identified in the lobby and dining hall, indicating failure to assure optimum readiness of the fire sprinkler system.
Several resident room doors would not close to latch in the closed position, compromising smoke resistance.
Fire doors on A-wing did not close and latch to stay closed on alarm activation.
Portable space heaters were located in the Assistant Dietician's Office and Admissions office, which is prohibited.
Report Facts
Staff and residents at risk: 60
Staff and residents at risk: 34
Staff and residents at risk: 65
Staff and residents at risk: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews related to fire safety deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 23, 2018
Visit Reason
A complaint survey was conducted to investigate complaints GA00183559 and GA00184353 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted in response to complaints GA00183559 and GA00184353; no deficiencies were found.
Findings
No deficiency was cited during the complaint survey.
Inspection Report
Abbreviated Survey
Census: 178
Deficiencies: 0
Date: Oct 17, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate allegations relating to quality of care and treatment at the facility.
Findings
The allegations relating to quality of care and treatment were found to be unsubstantiated during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 30, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaint #GA00179070 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint investigation #GA00179070 was conducted and no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Census: 181
Deficiencies: 0
Date: Aug 24, 2017
Visit Reason
An abbreviated survey was conducted to investigate allegations relating to accidents at the facility.
Complaint Details
Allegations relating to accidents were substantiated without deficiencies.
Findings
The allegations relating to accidents were substantiated without deficiencies.
Report Facts
Resident Census: 181
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 19, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00176786 and determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
Complaint #GA00176786 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 19, 2017
Visit Reason
A follow-up visit was conducted on 6/19/17 to verify correction of deficiencies identified in the prior recertification survey.
Findings
The follow-up survey found that the previously identified deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 12, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 8, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA 00175801 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA 00175801 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey at Sadie G. Mays Health & Rehabilitation Center.
Inspection Report
Life Safety
Census: 182
Capacity: 206
Deficiencies: 3
Date: Apr 25, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain kitchen hood fire prevention, corridor doors not positively latching, and uncovered voided circuit space in the kitchen electrical panel, placing staff and residents at risk.
Deficiencies (3)
Kitchen suppression Red Rubber Spray heads over cooking appliances were not in place to prevent grease accumulation.
Resident room #D3 door would not close to positively latch to hold in the closed position.
Voided Circuit space in the kitchen 'EK' electrical panel box was not covered as required.
Report Facts
Census: 182
Total Capacity: 206
Staff at risk: 12
Residents at risk: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to kitchen fire prevention, corridor door, and electrical panel deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 22, 2017
Visit Reason
A complaint investigation (GA00174096) was initiated and concluded on 4/22/17 to assess compliance with long term care requirements.
Complaint Details
Complaint investigation GA00174096 was conducted and the facility was found compliant with no deficiencies.
Findings
The facility was found to be in compliance with 42 CFR, Part 483, Subpart B for Long Term Care Requirements. No deficiencies were cited.
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